Quality Improvement Committee Patient Experience and Clinical Excellence: FY14 YTD, Jan. 14

1. Quality ImprovementCommitteePatient Experience and Clinical Excellence: FY14 YTD, Jan. 14 Presenter: Dr. George Block, CMO Ashraf Gulzar, Director Quality Management Mike Thornton, Supervisor Quality Management Date: May 28, 2014

2. Framework for Clinical ExcellenceMeasures that align national initiatives to the front line Measure Domains • Heart Failure, AMI, Pneumonia, SCIP, VTE, Immunization, Stroke, IP ED Throughput, Pregnancy Care Evidence-based Care VBP VBP VBP VBP VBP PFP PFP • Risk Adjusted Mortality Ratio • Sepsis/Documentation(Medicare - AMI, PN, CHF, COPD, Stroke, Hip/Knee) Mortality • PSI-90 + HAI + AHRQ PSI + Composite Harm Index (30 measures/6 LHM priorities) Safety • 30-day all cause readmissions (Medicare - AMI, PN, CHF, COPD, Stroke, Hip/Knee) Appropriate Hospital Use • HCAHPS Overall Rating 9-10 • Likelihood to Recommend Patient and Family Engagement • Length of Stay • Inlier Opportunity Index (IOI) Cost and Efficiency • Measures to be developed. $ $ Community Health PFP=Partnership for Patients VBP = Value Based Purchasing $ = standalone payment penalty 2

3. Evidence-based Care Desired Trend Evidence-Base Care Patient Experience Mortality • Notes: • Staff education • Nursing Competency • Daily core measure list • PCI task force • Immunization rounds • Meeting with Nursing Directors/ Managers for individual performance issues. • PN – Blood C/S ED issue (need to work with ED) Harm Readmissions Cost of Care

4. Evidence-based Care Desired Trend Evidence-Base Care • Notes: • Staff education • Nursing Competency • Daily core measure list • Foley rounds • Meeting with Nursing Directors/ Managers for individual performance issues. • ARCIS DVT assessment documentation changed for patient transferring to higher level of care. Patient Experience Mortality Harm Readmissions Cost of Care

5. Patient ExperienceHCAHPS Desired Trend Evidence-Base Care Patient Experience • Notes: • Studer training • (Apr – May 2011) • Leader rounding on Associates • (Sept. – Oct. 2011) • AIDET training • (Jan. – Mar. 2012) • Charge Nurse Rounding • (Apr. - May 2012) • AIDET Validation • (Jan. – Mar. 2013) • Difficult Conversation Training • (Feb. 2013) • Leader Patient Rounding • (Apr. 2013) Mortality Harm Readmissions Cost of Care *Stoplight report to be presented monthly

6. Patient Satisfaction Emergency Department Desired Trend Evidence-Base Care Patient Experience • Notes: • Studer training • (September 2013) • 2. Initiated Leader • Rounding in ED Mortality Harm Readmissions Cost of Care

7. Emergency DepartmentThroughput Desired Trend Evidence-Base Care Patient Experience Mortality Notes: 1. I.O.T. Committee oversee ED throughput process. Harm Readmissions Cost of Care

8. Mortality: Risk Adjusted Ratio Desired Trend Evidence-Base Care Patient Experience • Notes: • Mortality Drill down (Jan – March 2013) • IHI trigger tool • Coding issues such as comfort care or palliative care • Change in peer review form. • Reassess criteria for mortality screening. • Review of peer process at Medical Staff Retreat Mortality Harm Readmissions Cost of Care

9. Mortality: Observed Rate (Condition Specific) Desired Trend Evidence-Base Care Patient Experience Mortality Harm Readmissions Cost of Care

10. Mortality: Observed Rate(Condition Specific) Desired Trend Evidence-Base Care Community Engagement Patient and Family Engagement Notes: Total Hip and Knee, Stroke, and COPD mortality rates are new focus areas for CMS as of January 2014. Mortality Safety Appropriate Hospital Use Cost and Efficiency

11. Harm – Overall Composite and Focus Areas Desired Trend • Notes: • Outlier cases referred to • Medical Staff for peer • review in June 2013. • Outlier cases reviewed • and reported to Nursing • Quality Committee. • 3. For all inpatients, our PSI- • 90 HARM composite • score is at 1.073 and this • score is higher than • Medicare patients. As • this measure has just • become available, we will • need to investigate but it • is probably the number of • accidental puncture/ • laceration patients in the • All Payor population. Evidence-Base Care Patient Experience Mortality Harm Readmissions Cost of Care

12. Harm Focus Areas Desired Trend • Notes: • SUP Therapy discontinued when patient leaves ICU in Nov. 2012. • Antibiotic Stewardship Program implemented 4/2009. • Daily CAUTI Catheter Utilization Surveillance in March 2012. • TRUDI U.V. Robot for C.Diff decontamination in Oct. 2013 Evidence-Base Care Patient Experience Mortality Harm Readmissions Cost of Care

13. Readmissions: Overall and Condition Specific Desired Trend • Notes: • LACE tool completed by Case Managers in 3M 03/2013. • RAAD tool being • refined. • CHF Clinic 10/14/2013. • HCNC SNF • Collaborative • 12/2013. • EMMI pt. education started 10/2013. • Improved mgmt. • review of discharge • planning process. Evidence-Base Care Patient Experience Mortality Harm Readmissions Cost of Care

14. Appropriate Hospital Use: Condition Specific Desired Trend Evidence-Base Care Community Engagement Patient and Family Engagement Mortality • Notes: • Total Hip and Knee, Stroke, and COPD readmissions are new focus areas for CMS as of January 2014. Safety Appropriate Hospital Use Cost and Efficiency

15. Cost Effectiveness Desired Trend • Notes: • Utilization Mgmt. • Committee oversees • this process. • Medical Staff Advisors available for expert opinion during case review and may consult with medical staff as needed. • Excellent application of discharge planning process has aided in decreasing I.O.I. Evidence-Base Care Patient Experience Mortality Harm Readmissions Cost of Care

17. Financial risks on quality and cost OCT2011 OCT 2012 OCT2013 OCT2014 OCT2015 OCT2016 OCT2017 OCT2018 OCT2019 OCT2020 Value-Based Purchasing (VBP) 1.0% 1.25% 1.5% 1.75% 2.0% 30-day readmissions 2.0% 3.0% 1.0% 1% 2% Hospital-acquired conditions 1.0% Market basket reductions 0.1% 0.1% 0.3% 0.2% 0.75% Multifactor Productivity Adjustment* 0.7% 0.65% 0.9% 1.0% 0.7% 0.5% 0.5% 0.4% 0.5% Documentation and Coding Adjustment (DCA)** 4.9% 1.9% 2.1% 2.1% 2.1% 2.1% Across the board cuts to finance the debt *** 2.0% 10.6% 9.4% 8.7% 6.0% 10.5% 6.7% 8.1% 11.4% 9.3% 8.9% TOTAL IMPACT 10% % = % of medicare inpatient operating payments *The Multifactor Productivity Adjustment is an estimate generated by the CMS Office of the Actuary **DCA, also known as the behavioral offset, shown here does not show the future affects of these cuts on baseline spending. Estimates FY 2014-FY 2017 impact of the American Taxpayer Relief Act of 2012*** If Congress has not adopted the Joint Committee’s report to reduce the deficit by at least $1.2 trillion, the 2% cut will be implemented January 2013

18. New HAC policy 10/1/14 and overlapping HACs *SSI includes different conditions. ** Vascular Catheter is broader than the CLABSI measure.

19. Measure evolution toward outcomes and efficiency Hospitals’ VBP payment will increasingly be based on their performance on outcomes/efficiency FY 2013 FY 2014 FY 2015 Active Performance Period Clinical process Patient experience Outcomes Efficiency